facial palsy and its management

1. PG OMFS
Facial Paralysis &
its management

2. Outlines
 Anatomy
 Classification of nerve injuries
 Evaluation
 ElectroDiagnostic testing
 Bell’s palsy
 Medical management
 Surgical management

3. Anatomy of Facial nerve
 The facial nerve contains approximately 10,000
fibers
 7000 myelinated fibers innervate the muscles of
facial expression, stapedius muscle,
postauricular muscles, posterior belly of digastric
muscle, and platysma
 3000 fibers form the nervus intermedius (Nerve
of Wrisberg)
 sensory fibers (taste) from the anterior 2/3 of the
tongue
 taste fibers from soft palate via palatine and greater
petrosal nerve

4. Anatomy of Facial nerve
1) Intracranial part
 Supranuclear segment
 Nuclear segment
 Infranuclear segment
 Cerebellopontine angle
 Internal acoustic canal
 Labyrinthine segment
 Tympanic segment
 Mastoid segment
2) Extracranial part

5. Supranuclear
segment
 Cerebral cortex 
Corticobulbar tract
 Facial nucleus
(pons)
 Upper face 
crossed & uncrossed
 Lower face 
crossed only

6. Nuclear segment
 Facial motor nucleus
lower 1/3 of Pons
 abducent nucleus
 Out from brain stem at pons recess
between olive and inferior cerebellar peduncle

7. Nervous intermedius
 Parasympathetic secretory fibers arise
from superior salivatory nucleus
 These preganglionic fibers travel to the
submandibular ganglion via the chorda
tympani nerve to innervate the
submandibular and sublingual glands
 And to sphenopalatine ganglion via greater
superficial petrosal nerve to innervate
lacrimal, nasal, and palatine gland

10. Nervous intermedius
 Secretory fibers of lesser superficial
petrosal nerve tranverse tympanic
plexus, synapse in otic ganglion,
and travel via auriculotemporal
nerve to innervate parotid gland
 Taste fibers from anterior 2/3 of
tongue reach geniculate ganglion
via chorda tympani nerve and from
there travel to the nucleus of the
tractus solitarius

11. Infranuclear
segment

12. Cerebellopontine angle
 The facial nerve and nervus intermedius exit the
brain stem at the pontomedullary junction and
travel with CN VIII to enter the internal acoustic
meatus
Internal acoustic
canalMotor facial nerve (medial)
Nervus intermedius (between)
Acoustic nerve (lateral)

14. Labyrinthine segment
 Fallopian canal
 Shortest & Narrowest part
 Temporal bone
 Facial nerve enter fallopian canal until middle
ear
 First genu
 Geniculate ganglion
 Branches
 Greater superficial petrosal nerve  lacrimal gland
 Lessor superficial petrosal nerve  parotid gland

15. Tympanic segment
 First genu  above oval window  stapes
 Second genu beyond middle ear
 Out of cranium through stylomastoid foramen

16. Mastoid segment
 Stylomastoid foramen
 Branches
 Motor nerve to stapedius
muscle
 Chorda tympani nerve
between malleus and incus
 secretomotor : Submandibular &
Sublingual gland
 taste fiber : anterior 2/3 of
tongue

18. Extracranial segment
 Posterior auricular nerve : auricularis,
occipitalis and sensation at auricular, post
auricular area
 Branch to posterior belly of digastric muscle
and stylohyoid muscle
 Temporal branch : muscle above zygoma
 Zygomatic branch : orbicularis occli
 Buccal branch : buccinator and upper lip
 Marginal mandibular branch : orbicularis oris
and lower lip
 Cervical branch : platysma

20. Muscles of facial
expression

21. Classifications
Sunderland classification of
nerve injury
1° damage = Compression
2° damage = Interruption of axoplasm
3° damage = Disruption of myelin
4° damage = Disruption of
perineurium, myelin
and axon
5° damage = Transection of nerve

22. Sunderland Classification
of nerve injury

23. Classifications of facial nerve
injury
Seddon classification of nerve
injury
 Neuropraxia
 Axonotmesis
 Neurotmesis

24. Nerve injury
 neurapraxia ~ Sunderland grade 1
 axonotmesis ~ Sunderland grade 2-3
 neurotmesis ~ Sunderland grade 4-5

25. Differential Diagnosis
1. Extracranial
2. Intratemporal
3. Intracranial

26. Extracranial
1. Traumatic
Facial lacerations
Blunt forces
Penetrating wounds
Mandible fractures
Iatrogenic injuries
Newborn paralysis

27. Extracranial
2. Neoplasm
Parotid tumors
Tumors of the external and middle ear
Facial nerve neurinomas
Metastatic lesions
3. Congenital absence of facial
musculature

28. Intratemporal
1. Traumatic
Fractures of petrous pyramid
Penetrating injuries
Iatrogenic injuries
2. Neoplastic
Cholesteatoma
Facial neurinomas
Hemangiomas
Meningiomas
Acoustic neurinomas

29. Intratemporal
3. Infectious
 Herpes zoster oticus
 Acute otitis media
 Chronic otitis media
 Malignant otitis externa
4. Idiopathic
 Bell's palsy
 Melkersson-Rosenthal syndrome
5. Congenital: osteopetroses

30. Intracranial
1. Iatrogenic injury
2. Neoplastic
3. Congenital
 Mobius syndrome
 Absence of motor units

32. House-Brackmann grading
system
 The most commonly used facial nerve grading scale
is the House-Brackmann (HB) scale.
 The HB scale is used to approximate the quantity of
volitional motion the patient has based on their clinical
facial presentation
 Only grade six (6/6) presentations require EnoG
testing. That is, the purpose of the test is to determine
whether or not the facial nerve is neurophysiologically
intact. Therefore, if the patient has any volitional
motion (as would be evident with grades one through
five) the facial nerve is intact.
 It is useful to chart the progress of facial nerve
disorders via ENoG even in cases with grades two
through five presentations.

33. Grade II - Mild dysfunction, slight weakness on
close inspection, normal symmetry at rest

34. Grade III - Moderate dysfunction, obvious but not
disfiguring difference between sides, eye can be
completely closed with effort

35. Grade IV - Moderately severe, normal tone at rest,
obvious weakness or asymmetry with movement,
incomplete closure of eye

36. Grade V - Severe dysfunction, only barely perceptible
motion, asymmetry at rest

37. Topographic Diagnosis
 To determine the anatomical level of a peripheral
lesion
 Lacrimation  Geniculate ganglion
 Stapedius reflex  motor nerve of stapedius
muscle
 Taste  chorda tympani

38. Schirmer's Test
 Geniculate ganglion &
petrosal nerve function
test
 Schirmer’s test +ve
when
 Affected side shows
less than half the
amount of lacrimation
seen on the normal
side
 Sum of the lengths of
wetted filter paper for
both eyes less than
25 mm
 Lesion at or proximal to

39. Stapedius reflex
 Nerve to Stapedius
muscle test
 Impedance audiometry
can record the
presence or absence of
stapedius muscle
contraction to sound
stimuli 70 to 100 dB
above hearing
threshold
 An absence reflex or a
reflex less than half the
amplitude is due to a

40. Taste (Electrogustometry)
 Chorda tympani nerve test
 Solution of salt, sugar, citrate, quinine or
Electrical stimulation
 Compares amount of current require for a
response each side of tongue
 Normal : difference < 20 uAmp (thresholds
differening by more than 25%= abnormal)
 Total lack of Chorda tympani : No response at
300 uAmp
 Disadvantage : False +ve in acute phase of
Bell’s palsy

41. SALIVARY FLOW TEST

42. Electro Neuronography

43. ELECTROMYOGRAPHY
 Voulantary muscle response
 Latency,amplitude
 Denervation,renervation

44. IMAGING :

46. Idiopathic facial palsy (Bell's Palsy)
 Most common cause of facial paralysis
(>50% of case)
 Most age 25-30 yrs.
 Male : Female = 1 : 1
 Left side : Right side = 1 : 1
 Unilateral > bilateral
 Increase risk in
 pregnancy 3.3 times
 DM 4.5 times
 Recurrent rate 10%
 60% have previous URI

47. Etiology
 Unknown
Viral infection (HSV)
Ischemic neuropathy
Autoimmune reaction

49. Non Surgical Management

51. Medical treatment
 Corticosteroids :
prednisolone 1 mg/kg/day 7-10 days
 Corticosteroids combine with
antiviral drug is better
 Acyclovir 400 mg 5 times/day
 Famciclovir and valacyclovir 500 mg
bid

53. Surgical treatment
 Facial nerve decompression
 Indication
Completely paralysis
ENOG less than 10% in 2 weeks
 Appropriate time for surgery is 2-3
weeks after paralysis

54. The Brow
 A brow lift by direct excision of tissue through an
incision just above the eyebrow is the most
effective technique.
 Coronal
 Endoscopic lift .

55. BROW LIFT

56. coronal

57. BOTOX -
CHEMODENERVATION

58. EYE
 Sterile artificial drops 1-2hrs
(carboxy, hydroxy methyl cellulose
poly vinyl alchol)
 Ointmnt- inside lid
( mineral oil,white petroleum,lanolin)
 Eye glasses
 Plastic shields
 Eye bubble moist chambers

59.  Soft lenses
 Punctal plugs

60. TAPES

61. EYE BUBBLE

62. Botox

63. The Upper Eyelid
 The simplest effective procedure is lid loading
with a gold prosthesis.
 The lightest weight that will bring the eyelid within
2 to 4 mm of the lower lid and cover the cornea is
quite adequate.
 The effectiveness of a gold weight placement can
be determined preoperatively by taping the test
weight with double-sided tape to the upper eyelid.

65. GOLD WEIGHT IMPLANT

66. TARSORRHAPHY

67. CANTHOPLASTY

69. Palpebral spring as
described by Morel-Fatio

72. NERVE REPAIR

73.  Direct nerve repair:
 Usually possible for traumatic or iatrogenic injury to
nerve

 Facial nerve grafting:
o Best performed within 3 weeks to 1 year of injury
o Immediate grafting after ablative surgery yields good
results
o Sources of cable grafts – cervical plexus, sural nerve
o Method of choice - no tension epineural repair


74. GREATER AURICULAR
 < 6cm
 Ideal graft

75. SURAL NERVE
Reduces
 Morbidity
 Sensation
 Neuromatous pain

76. MEDIAL ANTEBRACHIAL
CUTANEOUS NERVE
 Total facial nere reconstruction from main trunk to
periphery

77. FACIAL REANIMATION -
REINNERVATION TECHNIQUES

78. 
 Nerve crossovers:
o Used when direct suturing or grafting is not feasible
o But movement is uncoordinated (synkinesis) and there
is loss of function in the donor nerve
• Synkinesis can be palliated by injections of botulinum toxin
around orbicularis oculi muscle.
• This reduces involuntary closure of the eye when
attempting to smile.
o Donor nerves – glossopharyngeal, accessory, phrenic,
hypoglossal
o Most suited to immediate reconstruction of facial nerve
trunk as part of primary ablative surgery

80. HYPOGLOSSAL FACIAL
TRASFER

81. CROSS FACE NERVE GRAFT

82. Cross facial nerve graft with muscle
transplantation – 2 stage procedure

83. FASCIO-FACIAL CROSS GRAFT

84. LOWER LIP ASYMETRY
CORRECTION

85. CHEMODENERVATION
 Botulinum toxin to weaken contralateral side

86. Resection
of DLI

87. PLATYSMECTOMY

88. Anterior belly of Digastric transfer

89. Lower lip / Marginal Mandibular
nerve palsy

92. TEMPORALIS TRANSFER

94. GRACILIS FREE MUSCLE
TRANSFER

96. MASSETER

97. STATIC SLING
 TENSOR FASCIA LATA
 ACELLULAR DERMIS
 PTFE

98. NASOLABIAL FOLD
MODIFICATION

99. NASAL VALVE REPAIR

100. Static sling procedure

101. SMAS RHITIDECTOMY STATIC
SLING SUSPENSION

102. references
 Facial nerve by William slattery
 web

103. THANK YOU